Perfusion Questions
A transfusion of packed red blood cells (PRBCs) has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should the nurse take first? 1. Obtain a warm blanket for the patient. 2. Check the patient's oral temperature. 3. Stop the transfusion. 4. Administer oxygen.
3. Stop the transfusion. The patient's symptoms indicate that a transfusion reaction may be occurring, so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the patient may not be appropriate. Checking the patient's temperature and administering oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority.
Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease? a. Esophageal pain may imitate the symptoms of a heart attack. b. GERD may predispose the client to the development of heart disease. c. Strenuous exercise may exacerbate reflux problems. d. Similar laboratory study changes may occur in both problems.
a. Esophageal pain may imitate the symptoms of a heart attack. Clients may interpret symptoms associated with myocardial infarction as esophageal reflux and ignore them. GERD does not predispose the client to heart disease. Exercise does not seem to exacerbate esophageal reflux problems unless the stomach is full when exercising. Exercising to maintain a healthy weight helps reduce esophageal reflux. Laboratory workups help differentiate these 2 diagnoses. Tests, such as cardiac enzymes, can help reveal a myocardial infarction, thereby facilitating differentiation between these problems.
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? a. I have abnormal platelets." b. "I have abnormal hemoglobin." c. "I have abnormal hematocrit." d. "I have abnormal white blood cells."
b. "I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
A primary health care provider prescribes atenolol 20 mg by mouth four times a day. Which information is important for the nurse to include in the discharge teaching plan for this client? a. Drink alcoholic beverages in moderation. b. Avoid abruptly discontinuing the medication. c. Increase the medication if chest pain develops. d. Report a pulse rate less than 70 beats/minute
b. Avoid abruptly discontinuing the medication. An abrupt discontinuation of atenolol may cause an acute myocardial infarction. Alcohol is contraindicated for clients taking atenolol because it can cause additive hypotension. Clients should never increase medications without a health care provider's direction. The pulse rate can go much lower as long as the client feels well and is not dizzy.
When caring for a client hospitalized with deep vein thrombosis, which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis? a. Daily aspirin use b. Frequent ambulation c. Warm soaks to legs d. Avoidance of cold
b. Frequent ambulation Frequent ambulation decreases venous stasis and helps prevent recurrent venous thrombosis. Clients who are hospitalized with deep vein thrombosis will be discharged on an anticoagulant such as warfarin; aspirin use is insufficient to prevent recurrent venous thrombosis. Warm soaks to the legs may help with the pain associated with thrombophlebitis, but they will not prevent recurrence. Avoidance of cold might be suggested for clients with peripheral arterial disease, but it is not needed for clients with venous disease or thrombophlebitis.
Which is the priority nursing care after a child has a cardiac catheterization procedure? a. Encouraging early ambulation b. Monitoring the site for bleeding c. Restricting fluids until the blood pressure has stabilized d. Comparing blood pressure readings in the lower extremities
b. Monitoring the site for bleeding Hemorrhage is a major life-threatening complication because arterial blood is under pressure and a catheter has been inserted into an artery. The child is kept in bed for 6 to 8 hours after an arterial catheterization. Fluids may be given as soon as they are tolerated. Pulses, not blood pressure, must be compared for quality and symmetry.
A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively? a. Decreased anxiety b. Reduced chest pain c. Decreased heart rate d. Increased blood pressure
c. Decreased heart rate A decreased heart rate is the expected response to a beta blocker. Beta blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta blockers reduce blood pressure.
Which position increases cardiac output in the obstetrical client with cardiac disease? a. Trendelenburg b. Low semi-Fowler c. Lateral positioning d. Supine with legs elevated
c. Lateral positioning Lateral positioning improves the cardiac output of an obstetrical client with cardiac disease. Trendelenburg, low semi-Fowler, and the supine position are not appropriate positions to improve the cardiac output of an obstetrical client with cardiac disease. Placing the client in these positions allows the weight of the uterus to remain on the vena cava, impeding the blood flow.
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the medication, the client complains of feeling dizzy. Which action will the nurse take? a. Determine if this is an allergic reaction. b. Elevate the client's head and keep the extremities warm. c. Place the client in the supine position and take the vital signs. d. Tell the client that this is not a typical sensation after receiving morphine sulfate.
c. Place the client in the supine position and take the vital signs Dizziness is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, cardiac output, and blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.
When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client? a. Getting up from bed in the morning b. Walking to visit the next-door neighbor c. Climbing a flight of stairs to the bedroom d. Leaving the table immediately after a meal
c. climbing a flight of stairs to the bedroom Stair climbing increases oxygen consumption and increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension; the oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion of a meal increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.
Several minutes after the start of a red blood cell infusion, the client reports itching. The nurse observes hives on the client's chest. Which action would the nurse take? a. Administer an antihistamine. b. Flush the red blood cells with 5% dextrose. c. Slow the rate of infusion. d. Stop the transfusion.
d. Stop the transfusion. The client is experiencing an allergic reaction to the transfusion. The nurse would stop the transfusion immediately. The health care provider then should be notified. An antihistamine may be indicated but must be prescribed. Flushing red blood cells with dextrose will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate but continuing the infusion will make the situation worse.
Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for which purpose? a. To control postoperative fever b. To provide a constant source of mild analgesia c. To limit the postsurgical inflammatory response d. To provide prophylaxis against postoperative thrombus formation
d. To provide prophylaxis against postoperative thrombus formation Enoxaparin, a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and of prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not an analgesic. Enoxaparin is not an anti-inflammatory medication.
The nurse is caring for clients on a medical-surgical unit and identifies that which client has the highest risk for developing a pulmonary embolism? a. An obese client with leg trauma b. A pregnant client with acute asthma c. A client with diabetes who has cholecystitis d. A client with pneumonia who is immunocompromised
a. An obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.
The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider? a. Stools have been black in color. b. Bruising is present at the right groin. c. Home blood pressure today was 104/52 mm Hg. d. Home radial pulse rate has been 55 to 60 beats/min.
a. Stools have been black in color. Dark or tarry stools may indicate gastrointestinal bleeding, which is a possible adverse effect of both aspirin and clopidogrel. The client will need to continue on the medications but may need treatment with proton pump inhibitors or histamine2 blockers to decrease risk for gastrointestinal bleeding. The other findings will also be reported to the health care provider but will not require a change in the therapeutic plan for the client.
The nurse assessed a client's pulse rate and recorded the score as 3+. Which describes the strength of the pulse? a. Strong b. Bounding c. Expected d. Diminished
a. strong A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.
When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin? a. Vitamin K b. Vitamin D c. Vitamin B 1 d. Vitamin B 12
a. vitamin k Warfarin causes inhibition of vitamin K-dependent clotting factors, and use of vitamin K would affect the therapeutic effect of warfarin. Vitamin D has no effect on warfarin. Vitamin B 1 does not affect warfarin or clotting. Vitamin B 12 does not affect warfarin effectiveness.
A child who has iron-deficiency anemia tells the school nurse, "I get dizzy in gym class." Which is the most likely explanation for this symptom? a. Inflammation of the inner ear b. Sudden drop in blood pressure c. Insufficient cerebral oxygenation d. Decreased level of serum glucose
c. Insufficient cerebral oxygenation Decreased oxygen (O 2)-carrying capacity of the blood may result in hypoxia during exercise, when O 2 demand is greater. Although the other options may cause dizziness, they are not directly related to anemia.
The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.
3. Administer sublingual nitroglycerin. The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority.
Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider? 1. Temperature of 102.1°F (38.9°C) 2. Loud systolic murmur over sternum 3. Blood pressure of 110/88 mm Hg 4. Weak radial and pedal pulses to palpation
1. Temperature of 102.1°F (38.9°C) Because endocarditis is a concern with valvular disease, an elevated temperature indicates a need for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systolic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic stenosis and do not indicate an immediate need for further evaluation or treatment.
The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider? 1. Serum potassium is 3.4 mEq/L (3.4 mmol/L). 2. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L). 3. Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L). 4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).
4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L). The client's low-density lipoprotein level continues to be elevated and indicates a need for further assessment (e.g., the client may not be taking the atorvastatin), a change in medication, or both. Although statin medications may cause rhabdomyolysis, which could increase BUN and potassium, the client's BUN and potassium are not elevated. Although ongoing monitoring of liver function is recommended when statins are used, this client's AST is normal.
When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 0 to 10)
4. Chest pain level of 3 (on a scale of 0 to 10) Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing.
The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)
4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.
The unlicensed assistive personnel reports to the nurse that a patient with hypertension is experiencing a drop in blood pressure when sitting up after receiving his morning medications. The patient received furosemide 20 mg, a multivitamin, and quinapril 10 mg orally. What side effect does the nurse recognize? 1. Hypokalemia 2. Hyponatremia 3. Photosensitivity 4. Postural hypotension
4. Postural hypotension Furosemide is a loop diuretic, and quinapril is an angiotensin-converting enzyme inhibitor. Both lower blood pressure, and patients may experience a drop in blood pressure when sitting or standing, which is a classical sign of postural hypotension. Signs of low potassium include dry mouth, muscle cramps, and irregular heartbeat, and signs of low sodium include confusion, seizures, decreased mental activity, and weakness or fatigue. Photosensitivity is a side effect of furosemide, but it is increased sensitivity to sunlight.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? a. Client reports stools are black. b. Oxygen saturation is 93%. c. Respiratory rate is 25 breaths per minute. d. Client has an ecchymosis on the ankle
a. Client reports stools are black. Because anticoagulant use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the health care provider and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. A slightly elevated respiratory rate in a client with a pulmonary embolus is a compensatory mechanism to prevent hypoxemia. Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.
When a client is admitted to the postanesthesia care unit after surgery, how frequently will the nurse plan to assess the blood pressure? a. Every 3 to 5 minutes b. Every 10 to 15 minutes c. Every 20 to 30 minutes d. Every 40 to 60 minutes
b. Every 10 to 15 minutes During the first 2 postoperative hours, the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock. Checking every 3 to 5 minutes is unnecessary, unless the client becomes hemodynamically unstable. Checking every 20 minutes or longer is unsafe because it is too long a period of time between blood pressure readings for a client who just had surgery.
Which of the following would the client with palpitations from premature heartbeats be taught to avoid? a. Bananas b. Tomatoes c. Energy drinks d. Green leafy vegetables
c. Energy drinks Energy drinks should be avoided in the client with palpitations from premature heartbeats because they contain caffeine and can increase ectopic beats. Bananas and tomatoes are high in potassium and are not a contraindication for the client with ectopic beats. Dark green leafy vegetables should be avoided by the client taking warfarin, because the vitamin K content counteracts the medication's therapeutic blood thinning.
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? a. Level of consciousness and pupil size b. Characteristics of pain and blood pressure c. Quality of respirations and presence of pulses d. Observation of abdominal contusions and other wounds
c. Quality of respirations and presence of pulses Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABCs: airway-breathing-circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after ABC needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.
After the nurse has completed teaching about sclerotherapy for a client with varicose veins, which client statement indicates that more teaching is needed? a. "I can eat and drink normally in the hours before the procedure." b. "I will still need to wear compression stockings after the procedure." c. "I can plan to take acetaminophen or ibuprofen for pain after the procedure." d. "I should return to the clinic immediately if there is any swelling at the procedure site."
d. "I should return to the clinic immediately if there is any swelling at the procedure site." Because sclerotherapy causes inflammation of the affected vein, swelling is expected and not a reason to return to the clinic. No general anesthesia is used for sclerotherapy, so clients may eat and drink normally. Ongoing use of compression stockings is recommended to prevent more varicosities from developing. There is usually minimal pain after sclerotherapy and mild analgesics such as acetaminophen or ibuprofen are adequate for pain control.
Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? a. Evaluating the patient's reports of chest pain b. Monitoring laboratory values for changes in oxygenation c. Assessing for symptoms of respiratory failure d. Auscultating the lungs for crackles
d. Auscultating the lungs for crackles An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.
During assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider immediately? 1. The patient reports pressure and pain. 2. The cast is in place and is dry and intact. 3. The skin is pink and warm to the touch. 4. The patient can move all the fingers and the thumb.
1. The patient reports pressure and pain. Pressure and pain may be caused by increased compartment pressure and can indicate the serious complication of acute compartment syndrome. This situation is urgent. If it is not treated, cyanosis, tingling, numbness, paresis, and severe pain can occur. The other findings are normal and should be documented in the patient's chart.
A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the emergency department health care provider. 3. Administer oxygen via nasal cannula. 4. Draw blood and establish IV access.
3. Administer oxygen via nasal cannula. The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen.
When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Take the patient's vital signs before the transfusion is started. 2. Assure that the blood is infused within no more than 4 hours. 3. Ask the patient at frequent intervals about presence of chills or dyspnea. 4. Assist with double-checking the patient's identification and blood bag number.
1. Take the patient's vital signs before the transfusion is started. UAP education and role includes obtaining vital signs, which will be reported to the RN prior to the initiation of the transfusion. Monitoring for transfusion reactions, adjusting transfusion rate, and assuring that the blood type and number are correct require critical thinking and should be done by the RN.
A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit
2. B-type natriuretic peptide Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the client has heart failure.
A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level
2. Troponin I level Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarction (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglobin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myoglobin is nonspecific. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction.
The vital signs of a 23-year-old man with no known health problems are unexpectedly abnormal. When the nurse mentions the vital signs, he says, "Well, I was a little nervous, so I smoked four or five cigarettes right before I came into the clinic." Which vital signs would be consistent with the patient's use of cigarettes? 1. Blood pressure of 90/60 mm Hg; pulse of 60 beats/min 2. Temperature of 100.6°F (38.1°C); respirations of 40 breaths/min 3. Blood pressure of 140/90 mm Hg; pulse of 120 beats/min 4. Temperature of 97.4°F (36.3°C); respirations of 12 breaths/min
3. Blood pressure of 140/90 mm Hg; pulse of 120 beats/min Nicotine promotes the release of norepinephrine and epinephrine. This can result in vasoconstriction, which elevates the pulse rate and the blood pressure.
The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client complains about a frequent dry cough. 4. Client says, "I get dizzy sometimes if I stand up fast."
3. Client complains about a frequent dry cough. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy.
Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles
3. Sinus bradycardia at a rate of 48 beats/min Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, a heart rate of 48 beats/min indicates a need to decrease the carvedilol dose.
Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct. a. Floss twice daily to prevent the need for dental work. b. Avoid eating hot food or liquid that can burn the mouth. c. Use an electric shaver instead of a straight-bladed razor. d. Apply ice to any areas of trauma like bumps and scrapes. e. Use enemas to prevent straining during bowel movements.
B, C, D The goal of self-care for clients on anticoagulation therapy is to prevent bleeding. Clients should avoid eating hot food or liquid, which can burn the mouth, disrupt the mucous membrane, and encourage bleeding. Clients should use an electric shaver instead of a straight-bladed razor to avoid cuts. Clients should be instructed to apply ice to any areas of trauma, such as bumps and scrapes, to slow blood flow and minimize bleeding. Clients on anticoagulation therapy should not floss because this can cause the gums to bleed; however, they should be encouraged to brush their teeth with a soft tooth brush and make sure their dentist knows they are on anticoagulants. Stool softeners, rather than enemas, should be used to prevent straining because enemas can cause rectal bleeding.
The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? a. lips b. sclera c. conjunctiva d. mucus membranes
a. lips The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? a. Maintain muscle strength b. Reduce leg discomfort c. Prevent clot formation d. Improve wound healing
c. prevent clot formation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Active ROM exercises will not improve wound healing.
Which assessment would the nurse include in the plan of care for a postpartum client with large, painful varicose veins? a. Monitoring daily clotting times b. Assessing for peripheral pulses c. Monitoring daily hemoglobin values d. Assessing for signs of thrombophlebitis
d. Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.
Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? a. Count the pulse at another site. b. Notify the primary health care provider. c. Lower the legs to increase blood flow. d. Verify the pulse by using a Doppler.
d. Verify the pulse by using a Doppler. Clients with venous insufficiency often have edema, which may make palpation of an arterial pulse difficult. A Doppler uses sound waves so that the pulse can be heard. The nurse is assessing for pulse presence and quality, not pulse rate, when checking pedal pulses. Because there is no indication that the client has arterial insufficiency, the nurse would not notify the primary health care provider about difficulty in palpating the distal pulses. Lowering the legs will increase edema and make palpation of pulses more difficult.
A client comes to the emergency department and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? Select all that apply. 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics
1,3,4,5,6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance. IV broad-spectrum antibiotics are usually ordered. A barium enema examination is not ordered if perforation is suspected.
During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.
1. Arterial line indicates a blood pressure of 190/112 mm Hg. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability.
A patient diagnosed with hypertension has received the first dose of lisinopril. Which interventions will the RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Restrict the patient to bed rest for at least 12 hours. 2. Recheck the patient's vital signs every 4 to 8 hours. 3. Ensure that the patient's call light is within easy reach. 4. Keep the patient's bed in a supine position with all side rails up. 5. Remind the patient to rise slowly from the bed and sit before standing. 6. Assist the patient to get out of bed and use the bathroom. 7. Assess the patient for signs of dizziness.
2,3,5,6 After the first dose of most antihypertensive drugs, dizziness is a common side effect. The patient should call for help when getting out of bed, and the call light should be within easy reach. The patient should rise slowly, sitting on the side of the bed before standing, and then can be assisted to the bathroom. The UAP's scope of practice includes these actions. Patients are not restricted to bed rest or kept in a supine (flat) position, and side rails are not all kept up for safety of the patient. Assessment is not within the scope of practice for a UAP. However, the RN could instruct the UAP to ask the patient about dizziness before and during ambulation and then report any dizziness immediately to the RN.
A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which action prescribed by the health care provider will the nurse implement first? 1. Administer morphine sulfate 4 to 8 mg IV. 2. Give oxygen at 4 L/min per nasal cannula. 3. Start an infusion of normal saline at 200 mL/hr. 4. Apply warm packs to painful joints.
2. Give oxygen at 4 L/min per nasal cannula. National guidelines for sickle cell crisis indicate that oxygen should be administered if the oxygen saturation is less than 95%. Hypoxia and deoxygenation of the blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control (including administration of morphine and application of warm packs to joints) and hydration are also important interventions for this patient and should be accomplished rapidly.
An older patient with type 2 diabetes has cardiovascular autonomic neuropathy (CAN). Which instruction would the nurse provide for the unlicensed assistive personnel (UAP) assisting the patient with morning care? 1. Provide a complete bed bath for this patient. 2. Sit the patient up slowly on the side of the bed before standing. 3. Only let the patient wash his or her face and brush his or her teeth. 4. Be sure to provide rest periods between activities.
2. Sit the patient up slowly on the side of the bed before standing. CAN affects sympathetic and parasympathetic nerves of the heart and blood vessels. It may lead to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing) caused by failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. The nurse should be sure to instruct the UAP to have the patient change positions slowly when moving from lying to sitting and standing.
The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood glucose level 3. Potassium level 4. Alkaline phosphatase level
3. Potassium level Hyperkalemia is a common adverse effect of both angiotensin-converting enzyme inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening.
A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable? a. Blue b. Gray c. Brick red d. Dark purple
c. brick red A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.
The nurse caring for a child with a low platelet count would monitor the child's urine for the presence of which component? a. Protein b. Glucose c. Erythrocytes d. Lymphocytes
c. Erythrocytes A low platelet count predisposes the child to bleeding, which may be evident in the urine. Red blood cells are seen microscopically in the sediment. Protein is not found in the urine when the platelet count is low. Glucose is not found in the urine when the platelet count is low. Lymphocytes usually are not found in the urine.
The nurse obtains this information when assessing a 3-year-old patient with uncorrected tetralogy of Fallot who is crying. Which finding requires immediate action? 1. The apical pulse rate is 118 beats/min. 2. A loud systolic murmur is heard in the pulmonic area. 3. There is marked clubbing of the child's nail beds. 4. The lips and oral mucosa are dusky in color.
4. The lips and oral mucosa are dusky in color. Circumoral cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee-chest position, administer oxygen, and take steps to calm the child. The other assessment data are expected in a child with congenital heart defects such as tetralogy of Fallot.
Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Select all that apply. One, some, or all responses may be correct. a. Wear a mask during the procedure. b. Clean the catheter exit site every day. c. Maintain meticulous aseptic technique. d. Wash your hands before the exchange. e. Store supplies in a clean and dry location
ALL ANSWERS ARE CORRECT The location of the peritoneal dialysis catheter makes it a direct portal to the peritoneum, which increases the client's risk for peritonitis. The nurse would ensure that the client understands the importance of preventing peritonitis when providing instructions on performing peritoneal dialysis. The client would be instructed to wear a mask during the procedure, especially when changing connector sets. The nurse would show the client how to properly clean the area around the catheter exit site and instruct that this be done every day to remove secretions. The client must be aware that meticulous aseptic technique throughout all phases of the exchange is essential. Proper hand-washing technique would be demonstrated and the client instructed on the importance of hand washing before the exchange. Supplies would be stored in a clean and dry place.
The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products? a. Stay with client during first 15 minutes of infusion. b. Flush packed red blood cells with 5% dextrose and 0.45% normal saline. c. Remove the intravenous catheter if a blood transfusion reaction occurs. d. Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.
a. Stay with client during first 15 minutes of infusion. The nurse would remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 mL of blood. Blood components are viscous, requiring a large needle to be used for venous access. A 20-gauge needle is not used to access a central catheter line. Normal saline is the solution to administer with blood productions. Lactated Ringer and dextrose in water are not used for infusion because of hemolysis.
The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining? a. Fluid retention b. Kidney function c. Nutritional status d. Medication dosage
a. fluid retention Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. Which is the best response by the nurse? a." It's a type of x-ray that shows us the size of the baby's heart." b. "Electrical activity in the baby's heart is recorded, then printed on graph paper." c. "It's an ultrasound procedure that produces images of the structures in the baby's heart." d. "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."
b. "Electrical activity in the baby's heart is recorded, then printed on graph paper." An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images of the structures in a baby's heart is the echocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.
A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case? a. Assess the amount and color of urine; obtain a specimen for a urinalysis and culture. b. Administer the prescribed antipyretic and notify the primary health care provider of this change. c. Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity. d. Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour
b. Administer the prescribed antipyretic and notify the primary health care provider of this change. Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.
The nurse is teaching a health awareness class. Which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? a. Pregnancy b. Inactivity c. Aerobic exercise d. Tight clothing
b. Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.
A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first? a. Give acetaminophen 650 mg PO. b. Administer ondansetron 4 mg IV. c. Infuse normal saline at 500 mL/hr. d. Increase oxygen flow rate to 6 L/min.
c. Infuse normal saline at 500 mL/hr. Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline. Treatment of nausea and headache are appropriate and should be implemented next. There is no indication that this client is hypoxemic, although clients with Ebola may develop multiorgan failure and require respiratory support.
Which clinical manifestation indicates a client may have an actively bleeding stress ulcer? a. Unexplained symptoms of shock b. Small amounts of melena for several days c. Sudden hematemesis and rectal blood d. A gradual drop in the hematocrit value
c. Sudden hematemesis and rectal blood Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; the shock resulting from the stress ulcer bleeding would be explained because the sudden gastrointestinal bleeding appears via hematemesis or via the stool. Sudden massive bleeding occurs, not the slow oozing resulting in melena. A gradual drop in the hematocrit value indicates slow blood loss.
When the preoperative nurse learns that a client is taking several herbal supplements, which action is the priority? a. Provide the client with information about the usefulness of herbal therapies. b. Inform the client about taking supplemental vitamins rather than herbs. c. Teach the client about herbal supplements. d. Ask the client which herbs have been taken
d. Ask the client which herbs have been taken The nurse must find out which herbs the client has been taking because some herbs can prolong bleeding, and the health care provider may need to postpone the surgery until the client has been free of herbal supplements for a period of time. Teaching the client about the usefulness of herbal therapies may be needed at another time, but the priority in the preoperative client is to determine whether the client is at risk for bleeding because of herbal therapy. Teaching about the benefits of vitamin supplements instead of herbal therapy may be needed, but the immediate preoperative time is not the best time for education on this topic. Teaching the client more about herbal supplements may be needed at another time, but the priority in the preoperative time is to determine exactly which herbal therapies the client has been using.
Which client response indicates to the nurse that a vasodilator medication is effective? a. Absence of adventitious breath sounds b. Increase in the daily amount of urine produced c. Pulse rate decreases from 110 to 75 beats/minute d. Blood pressure changes from 154/90 to 126/72 mm Hg
d. blood pressure changes from 154/90 to 126/72 mm Hg Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.
Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments
1,3,5,6 To avoid rehospitalization, topics that should be included when discharging a client with heart failure include low-sodium diet, purpose and common side effects of medications such as angiotensin-converting enzyme inhibitors and beta-blockers, what to do if symptoms of worsening heart failure occur, and follow-up appointments. The nurse will teach the client that a moderate increase in heart rate and respiratory effort is normal with exercise. Antibiotics are not included in the treatment regimen for heart failure, which is not an infectious process.
Which laboratory value would the nurse assess when preparing a client for a renal biopsy? Select all that apply. One, some, or all responses may be correct. a. Hematocrit b. Hemoglobin c. Platelet count d. Prothrombin time (PT) with international normalized ratio (INR) e. Partial thromboplastin time (PTT)
ALL ARE CORRECT The nurse would assess the client's hematocrit and hemoglobin before and after the procedure to determine blood loss. The nurse would also check the client's platelets, PT/INR, and PTT to determine if the client is at risk for hemorrhage.
How would anxiety affect outcomes for a client with heart failure? a. Increases the cardiac workload b. Interferes with usual respirations c. Produces an elevation in temperature d. Decreases the amount of oxygen used
a. Increases the cardiac workload Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure. Anxiety does not directly interfere with respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen needed for body functions.
A client with a diagnosis of anemia is receiving packed red blood cells. Which nursing action is important when administering the transfusion? a. Assessing the client for fluid overload b. Monitoring the client's response, particularly within the first 10 minutes c. Assuring that the transfusion flows at a consistent rate during the procedure d. Having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion
b. Monitoring the client's response, particularly within the first 10 minutes Transfusion reactions usually occur early during the administration of a blood transfusion (first 30 mL of blood); early detection of a transfusion reaction will permit a quick termination of the infusion. The risk of fluid overload is unlikely, and this information can be frightening. The donor's, not the recipient's, blood is tested for HIV. The flow rate will be slower during the first 10 to 15 minutes of the infusion to limit the amount of blood infused; this allows time to assess the client's response for signs and symptoms of a transfusion reaction before too much of the blood is infused.
Which assessment finding by the nurse caring for a client with new-onset atrial fibrillation would be most important to communicate to the health care provider? a. Irregular apical pulse b. Sudden vision change c. Exertional dyspnea d. Lower extremity edema
b. Sudden vision change Atrial fibrillation causes pooling of blood in the atria, leading to atrial clots and risk for stroke if clots are ejected from the left ventricle into the systemic circulation. A sudden onset change in vision may indicate stroke and would be immediately communicated to the health care provider so that actions such as rapid administration of thrombolytic medications can be considered. An irregular apical pulse is characteristic of atrial fibrillation and would not be immediately reported to the health care provider. Although exertional dyspnea would be reported to the health care provider, it is common with atrial fibrillation and does not require any immediate change in treatment. Edema may occur with atrial fibrillation because of decreased cardiac output, but it does not require an immediate change in treatment.
Which client finding would the nurse document as a pulse deficit? a. Blood pressure of 130/70 mm Hg indicating pulse deficit of 60 b. Capillary refill greater than 3 seconds indicating pulse deficit c. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 d. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10
c. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.
A patient with sickle cell disease is admitted with splenic sequestration. The blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of these actions will the nurse take first? 1. Complete a head-to-toe assessment. 2. Draw blood for type and cross-match. 3. Infuse normal saline at 250 mL/hr. 4. Ask the patient about vaccination history.
3. Infuse normal saline at 250 mL/hr. Because the patient is severely hypotensive, correction of hypovolemia caused by the splenic sequestration is the most urgent action. The other actions are appropriate because a complete assessment will be needed to plan care, a transfusion is likely to be needed, and vaccination history is pertinent for patients with sickle cell disease. However, infusion of saline is the priority need.
The RN is mentoring a student nurse who is caring for a patient with carpal tunnel syndrome of the right hand with neurovascular check ordered every 2 hours. For which action by the student nurse must the RN intervene? 1. Student nurse checks the patient's radial pulse every 2 hours. 2. Student nurse checks for sensation in the patient's right hand. 3. Student nurse assesses color, temperature, and pain in right wrist and hand. 4. Student nurse instructs the patient to avoid movement because of the pain.
4. Student nurse instructs the patient to avoid movement because of the pain. Performing complete neurovascular assessment (also called a "circ check") includes palpation of pulses in the extremities below the level of injury and assessment of sensation, movement, color, temperature, and pain in the injured part. If pulses are not palpable, use of a Doppler helps find pulses in the extremities. After surgery, the patient should be given pain medication and encouraged to move the fingers frequently. Some hand movements such as lifting heavy objects may be restricted for 4 to 6 weeks after surgery.
A health care provider prescribes a diuretic for a client with hypertension. Which mechanism of action explains how diuretics reduce blood pressure? a. They facilitate vasodilation. b. They promotes smooth muscle relaxation. c. They reduce the circulating blood volume. d. They block the sympathetic nervous system
c. They reduce the circulating blood volume. Diuretics decrease blood volume by blocking sodium reabsorption in the renal tubules, thus promoting fluid loss and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Medications that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.
The nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. Which rationale will prompt the nurse to ask the provider for a different form of metformin? a. This medication has a wax matrix frame that is difficult to crush. b. The medication has an unpleasant taste, which most clients find intolerable if crushed. c. If crushed, this medication irritates mucosal tissue and can cause oral and esophageal ulcer formation. d. Extended-release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring.
d. Extended-release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring. The slow-release formulary will be compromised, and the client will not receive the entire dose if it is chewed or crushed. The capsules are not difficult to crush. Irritation of the mucosal tissue is not the reason the medication should not be crushed; however, this medication should be given with meals to prevent gastrointestinal irritation. Although taste could be a factor, it is not the priority issue.
A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.
3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. The American Heart Association recommends home blood pressure monitoring for clients with hypertension or hypertension risk factors because home blood pressure monitoring provides more accurate data about usual blood pressure than periodic monitoring. The other actions may be necessary, but further assessment of the client's usual blood pressure is needed before decisions about therapy can be made.
When the thigh-high antiembolism stockings that have been prescribed for a client with varicose veins fit on the lower legs but are too small to fit over the thighs, which action would the nurse take? a. Slightly slit the top of the stockings to relieve pressure. b. Leave the antiembolism stockings off to prevent tissue damage. c. Roll the top of the stockings to below the knees to limit popliteal pressure. d. Ask the health care provider if an elastic bandage can be used in place of the stockings.
d. Ask the health care provider if an elastic bandage can be used in place of the stockings. An elastic bandage can be adjusted to the varying proportions of the client's legs. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.
